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Surgery of Septal Perforations

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Policlinico di Modena; Modena, Italy

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A wide variety of techniques and approaches to treat septal perforation have been described in the international literature, but the results of surgical closure remain less than satisfactory. The open rhinoplasty approach1 with an external columellar incision and the midfacial degloving approach2 (in larger perforations) are often preferred for wide exposition of the septum and the perforation. The endonasal approach is preferred by a minority of authors.3

Nasal mucosal flaps (from the nasal fossa floor or from the inferior turbinate) are the most used flaps.4 The use of forearm free flaps or oral mucosal flaps has also been described. Connective tissue grafts such as temporal muscle and fascia, pericranium, conchal cartilage, mastoid periosteum, and human acellular dermal allograft are commonly interposed between the repaired nasal mucosal flaps.

Our technique is based on an endonasal, endoscope-assisted approach, with the dissection of bilateral monopedicled mucosal flaps from the nasal fossa floor, without any graft interposition. The surgical approach begins with an anterior caudal septal incision (see Video, Supplemental Digital Content 1, which demonstrates the incision through the left nostril, http://links.lww.com/Axxx); the cut is extended to the floor of the nasal fossa (Fig. 1, above, left) and as far as under the inferior turbinate and posteriorly (see Video, Supplemental Digital Content 2, which shows the incision of the left nasal fossa floor, http://links.lww.com/Axxx). The dissection is made under the perichondral layer of the septum all around the perforation and over the nasal fossa floor (see Video, Supplemental Digital Content 3, which shows the incision of the perforation during the elevation of the flap, http://links.lww.com/Axxx) (Fig. 1, above, right). Once elevated, the flap is transposed medially and cranially to completely cover the perforation. The nasal fossa floor is left uncovered. The flap is then sutured to the mucosa of the upper margin of the perforation with a reabsorbable suture (see Video, Supplemental Digital Content 4, which demonstrates the sutures on the right side, http://links.lww.com/Axxx) (Fig. 1, below, left). The same approach is made on the other side, without interposition of any cartilage or connective graft (Fig. 1, below, right). The nasal package is mild, and is removed after 3 days.

The results from 31 patients showed a rate of closure of 96.3 percent of the perforations smaller than 3 cm after 1 year of follow-up (the highest rate of success reported in the international literature for that diameter). Nevertheless, according to our results, in perforations smaller than 3 cm, the interposition of a graft between the two mucosal layers is useless.

In perforations larger than 3 cm, results have not been equally satisfactory. In four patients considered, we had complete closure in only two.

The flaps, despite being monopedicled and often of wide dimensions, never showed vascular suffering. The epithelization of the nasal floor left uncovered is complete after 30 to 40 days (see Video, Supplemental Digital Content 5, which shows complete closure of the perforation with an epithelized nasal fossa floor at 30-day follow-up, http://links.lww.com/Axxx).

Our experience suggests that the endonasal endoscope-assisted approach can allow the best precision for verifying all the surgical steps; the absence of external scars and the absence of morbidity at the donor site for the graft represent advantages of this technique. We also think that only techniques with nasal mucosal flaps are able to achieve a normal nasal physiology, because they use the normal respiratory epithelium for closure.5

The high rates of success for the perforations smaller than 3 cm seem to confirm the effectiveness of this technique.

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David H. Song, M.D., M.B.A. is the President-elect of the American Society of Plastic Surgeons (ASPS). He is a consultant with BioMet, Emmi Solutions, LLC, a consortium-member providing senior debt for Brava, and consultant with and investor in HealthEngine.com. He receives author royalties from Elsevier. Scot Glasberg, M.D. is the President of the American Society of Plastic Surgeons (ASPS). He is a consultant with LifeCell Corp and Mentor Corp and an investor with Strathspey Crown. The authors have no sources of funding to report related to the writing or submission of this discussion.

The location and affiliation information should read as follows: Arlington Heights, Ill. From the American Society of Plastic Surgeons/Plastic Surgery Foundation.